Mechanism and Pathophysiology of Bleeding from Esophagogastric Varices

  • Kazuhiko OhoEmail author


Bleeding from ruptured esophagogastric varices is the main complication of portal hypertension and a major cause of death. The risk factors of variceal bleeding have been reported but are still debated. Variceal hemorrhage can be caused by various factors including topical, portal hemodynamic, and systemic factors.

A hepatic vein pressure gradient (HVPG) of 10–12 mmHg is required for the development of varices. Furthermore, an HVPG > 12 mmHg is necessary for the occurrence of variceal hemorrhage. Factors that further increase variceal wall tension causing it to reach a threshold and develop a topical mucosal disorder of varices may induce variceal hemorrhage. Considering these factors, management of esophagogastric varices must be performed.


Esophagogastric varices Variceal hemorrhage Red color sign Portal pressure Variceal wall tension 


  1. 1.
    Japanese Research Society for Portal Hypertension. The general rules for recording endoscopic findings on esophageal varices. Jpn J Surg. 1980;10:84–7.CrossRefGoogle Scholar
  2. 2.
    Beppu K, Inokuchi K, Koyanagi N, Nakayama S, Sakata H, Kitano S, et al. Prediction of variceal hemorrhage by esophageal endoscopy. Gastrointest Endosc. 1981;27:213–8.CrossRefGoogle Scholar
  3. 3.
    The North Italian Endoscopic Club for the Study and Treatment of Esophageal Varices. Prediction of the first variceal hemorrhage in patients with cirrhosis of the liver and esophageal varices. A prospective multicenter study. N Engl J Med. 1988;319:983–9.CrossRefGoogle Scholar
  4. 4.
    Kim T, Shijo H, Kokawa H, Tokumitsu H, Kubara K, Ota K, et al. Risk factors for hemorrhage from gastric fundal varices. Hepatology. 1997;25:307–12.CrossRefGoogle Scholar
  5. 5.
    Arakawa M, Kage M. The Anatomy and pathomorphology of esophageal varices. In: Okuda K, editor. Portal hypertension. Tokyo: Springer; 1991. p. 415–28.CrossRefGoogle Scholar
  6. 6.
    Hidaka H, Nakazawa T, Wang G, Kokubu S, Minamino T, Takada J, et al. Long-term administration of PPI reduces treatment failures after esophageal variceal band ligation: a randomized, controlled trial. J Gastroenterol. 2012;47:118–26.CrossRefGoogle Scholar
  7. 7.
    Sakamoto Y, Oho K, Toyonaga A, Kumamoto M, Haruta T, Inoue H, et al. Effect of Helicobacter pylori infection on esophagogastric variceal bleeding in patients with liver cirrhosis and portal hypertension. J Gastroenterol Hepatol. 2013;28:1444–9.CrossRefGoogle Scholar
  8. 8.
    Iijima K, Sekine H, Koike T, Imatani A, Ohara S, Shimosegawa T. Serum pepsinogen concentrations as a measure of gastric acid secretion in Helicobacter pylori-negative and -positive Japanese subjects. J Gastroenterol. 2005;40:938–44.CrossRefGoogle Scholar
  9. 9.
    Ledinghen VD, Heresbach D, Fourdan O, Bernard P, Liebaert-Bories M, Nousbaum J, et al. Anti-inflammatory drugs and variceal bleeding: a case-control study. Gut. 1999;44:270–3.CrossRefGoogle Scholar
  10. 10.
    Yoshida H, Mamada Y, Taniai N, Mineta S, Kawano Y, Mizuguchi Y, et al. Interactions between anti-ulcer drugs and non-steroidal anti-inflammatory drugs in cirrhotic patients with bleeding esophagogastric varices. Hepatogastroenterology. 2009;56:1366–70.PubMedGoogle Scholar
  11. 11.
    Garcia-Tsao G, Groszmann RJ, Fisher RL, Conn HO, Atterbury CE, Glickman M. Portal pressure, presence of gastroesophageal varices and variceal bleeding. Hepatology. 1985;5:419–24.CrossRefGoogle Scholar
  12. 12.
    Iwao T, Toyonaga A, Sumino M, Takagi K, Oho K, Sakaki M, et al. Development of gastroesophageal varices and risk of variceal bleeding in patients with cirrhosis. Dig Endosc. 1991;3:485–90.CrossRefGoogle Scholar
  13. 13.
    Tripathi D, Therapondos G, Jackson E, Redhead DN, Hayes PC. The role of the transjugular intrahepatic portosystemic stent shunt (TIPSS) in the management of bleeding gastric varices: clinical and haemodynamic correlations. Gut. 2002;51:270–4.CrossRefGoogle Scholar
  14. 14.
    García-Pagán JC, Feu F, Castells A, Luca A, Hermida RC, Rivera F, et al. Circadian variations of portal pressure and variceal hemorrhage in patients with cirrhosis. Hepatology. 1994;9:595–601.CrossRefGoogle Scholar
  15. 15.
    Iwao T, Oho K, Sakai T, Sato M, Nakano R, Yamawaki M, et al. Upright posture decreases esophageal varices blood flow velocity in patients with cirrhosis. J Hepatol. 1998;28:447–53.CrossRefGoogle Scholar
  16. 16.
    Iwao T, Oho K, Nakano R, Yamawaki M, Sakai T, Sato M, et al. Upright posture blunts postprandial splanchnic hyperemia in patients with cirrhosis and portal hypertension. J Gastroenterol. 1999;34:359–65.CrossRefGoogle Scholar
  17. 17.
    Polio J, Groszmann RJ. Hemodynamic factors involved in the development and rupture of esophageal varices: a pathophysiologic approach to treatment. Semin Liver Dis. 1986;96:318–31.CrossRefGoogle Scholar
  18. 18.
    Rigau J, Bosch J, Bordas JM, Navasa M, Mastair R, Kravetz D, et al. Endoscopic measurement of variceal pressure in cirrhosis: correlation with portal pressure and variceal hemorrhage. Gastroenterology. 1989;96:873–80.CrossRefGoogle Scholar
  19. 19.
    Kleber G, Sauerbruch T, Fischer G, Paumgartner G. Pressure of intraoesophageal varices assessed by fine needle puncture: its relation to endoscopic signs and severity of liver disease in patients with cirrhosis. Gut. 1989;30:228–32.CrossRefGoogle Scholar
  20. 20.
    Luca A, Cirera I, Garcia-Pagan JC, Feu F, Pizcueta P, Bosch J, et al. Hemodynamic effects of acute changes in intra-abdominal pressure in patients with cirrhosis. Gastroenterology. 1993;104:222–7.CrossRefGoogle Scholar
  21. 21.
    Kravetz D, Bildzola M, Argonz J, Romero G, Korula J, Munoz A, et al. Patients with ascites have higher variceal pressure and wall tension than patients without ascites. Am J Gastroenterol. 2000;95:1770–5.CrossRefGoogle Scholar
  22. 22.
    Kravetz D, Romero G, Argonz J, Guevara M, Suarez A, Abecasis R, et al. Total volume paracentesis decreases variceal pressure, size, and variceal wall tension in cirrhotic patients. Hepatology. 1997;25:59–62.CrossRefGoogle Scholar
  23. 23.
    Goulis J, Armonis A, Patch D, Sabin C, Greenslade L, Burroughs AK. Bacterial infection is independently associated with failure to control bleeding in cirrhotic patients with gastrointestinal hemorrhage. Hepatology. 1998;27:1207–12.CrossRefGoogle Scholar

Copyright information

© Springer Nature Singapore Pte Ltd. 2019

Authors and Affiliations

  1. 1.Department of Gastroenterology and HepatologyYanagawa HospitalFukuokaJapan
  2. 2.Kurume University School of MedicineFukuokaJapan

Personalised recommendations